At the hospital, I’m Dr. Nobody

Today I had a very special experience, one which many of my patients have faced: I was treated like a nobody while at the hospital. Yay me.

I went to visit a patient who was admitted over the weekend to see what was going on. She was a bit upset about the confusion of the hospitalist service and how orders apparently didn’t get written for her care by the admitting physician. That’s been resolved, but there are still many questions about what is going on with her and I thought that maybe I could help.

I was actually hired by this hospital when I first came to Augusta 20 years ago. They paid for my first two years’ salary and got my practice up and running. After concluding we could run our practice better than the hospital, we left their employment to run our own business.

I continued seeing inpatients in that hospital over the years, although I did give up the practice of admitting my own adult patients, opting to use the hospitalist service — something that was still fairly new when we went over to it. We felt that the negative of the loss of contact with our hospitalized patients would be greatly outweighed by the improved care we could give to the vast majority of patients who were not in the hospital.

This is a deal with the devil that many docs have made over the past few years, as the overwhelming burden of paperwork, codes, and insurance nonsense made us look for ways to simplify. It’s a deal with the devil, though, because we lose contact with patients when they need us most. This is made worse by the #1 rule most hospitalists seem to have: Never communicate with the PCP. I’m not sure why they have that rule, but it has been consistent through my years of practice. We PCP’s are either evil, stupid, or very dull conversationalists. Hospitalists hate us.

Still, I am well-known to most of the other physicians in that hospital. It carries a lot of memories and good feelings. I was actually a bit excited to go there and perhaps bump elbows with the doctors and nurses who still know who I am. But from the start, the experience was less than positive. Since I am now a “nobody,” I no longer have access to the doctor’s parking lot and had to park with the “common folk.” This is fine, but the patient lot bakes in the hot Georgia sun and was packed, resulting in a long, hot walk to the building.

The hospital’s changed a lot since I was seeing patients there. With all of the economic pressures they face, I find it curious how many multi-million dollar “improvements” get done on a regular basis. Walking in, it looked totally different and I knew nobody. The elevator was dressed nicely in real wood paneling and multiple advertisements for their da Vinci robotic surgery. They spent a lot of money on those robots, and need to get some of it back (despite a lack of evidence robotic surgery is better).

My patient’s ward was the usual mix of patient moans, nurse call chimes, IV alarms, and distracted nurses. I found the room and went in, greeted with a big smile from my patient and her husband. They told me the tale of woe, recounting the sickness itself, the ER experience, the orders neglected, the doctors not answering their pagers, and finally the nice hospitalist they finally saw. They couldn’t answer many of my questions, as they hadn’t really talked to many people despite two days passed.

I went out to get a pen so I could give my cell number to the hospitalist (hoping he doesn’t remember rule #1), plus I wanted to see if I could check the chart and get some answers for my patient. After being ignored by the nurses for a minute or so, I cleared my throat, winning an icy greeting from one of the nurses. I explained that I am a PCP and needed a pen, also expressing my hope that I could see the chart. “No,” she said simply. “You can’t look in the chart unless you have privileges and have been consulted.” She wordlessly added through her facial expression, “And stop wasting my time, you useless pile of crap.”

So now I wait, hope against hope that the hospitalist will break the hospitalist code and actually call me. Today’s experience made me once again see how badly our system treats people. I was Dr. Nobody while I was there. Each patient in that hospital seems like a nobody attached to a set of problem codes and procedure codes (which may, by the way, be fixable using da Vinci robotic surgery!). The nurses are overwhelmed and the doctors are hard to reach. They don’t know my patient, and will soon forget about her when she leaves. This is not health care, it’s a chaotic money-devouring machine.

I left there ever more committed to keeping my patients away from that mess. My patients are not nobodies; they are people I’ve taken the time to get to know. To them I am not Dr. Nobody; I am their doctor.

At the hospital, I’m Dr. Nobody 19 comments

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Ed

Why can’t the patient just ask to see the chart and hand it over to their PCP.

http://doctor-rob.org/ Dr. Rob

Patients don’t have free access to their own chart. I think if they raised enough of a stink (or if I did, for that matter), they’d relent. I don’t know at all why I didn’t have access. I’ve gone to my patients in the past and written a “PCP reviewed chart” note without trouble. They will send me any notes I ask in the future. I think the nurse was wrong. Still, that’s the basic tone of the relationship between hospitals and PCPs (at least in our area).

DeceasedMD

How did we get here? I must have taken a wrong turn in the road somewhere except we have ended up in the very same place. The very rule of medicine-to collaborate is violated here.

I have particularly noticed that staff at hospitals are generally condescending, except they most often are quite oblivious to it. They do not treat MD’s differently. I think this is 2 fold. Their boss is bureaucracy. And they seem to lack the ability to differentiate a Pt’s PCP from their mother. They are married to rules and there is no place for common sense only HIPAA. They usually sound like robots, that use the most possible words to explain the most simplistic ideas. They are so busy following rules that there is no doubt it renders them incapable of thinking rationally. In the past, staff were respectful to MD’s. That day is long gone.

FEDUP MD

Apparently you have to go through medical records or it is a violation of HIPAA or some ridiculousness. I have been told if I look up my own chart that I am violating HIPAA. Yup, apparently I can violate my own privacy. We were also told by administrators that patients could not look at the chart in real time but had to get them through medical records, obviously with a delay. Seems like a bad idea to me but apparently that is coming from all the lawyers. I think Shakespeare had the right idea about what to do with all the lawyers.

Ed

My layman read of HIPAA (for what that’s worth) says we can access (read) our records without the nonsensical wait. Seems there would be a huge liability issue for the hospital if a patient insisted their PCP review the chart, and was subsequently denied. I mean, really, the one physician that the patient truly trusts being denied access sounds like a great opportunity for lawyers to get involved. This is a paternalistic control issue and nothing more!

http://doctor-rob.org/ Dr. Rob

Agree – and you know what, they are going to send me a copy of those records once she’s discharged! Since I am PCP, I don’t need a release of information to get the records. I think she was clearly wrong to deny me access to the records. The bigger problem is the absolutely impersonal industrial atmosphere at the hospital. It’s not a place of care for the sick; it’s a procedure and protocol factory.

rtpinfla

You are kinda close in your assessment. It’s a medicare/insurance money mining factory that is protocol/procedure driven.

Eric Strong

HIPAA requires that patients have access to their medical charts, but it also requires that hospitals log all requests to see a patient’s chart (requests from the patient him/herself are not excluded from this rule). Therefore, for a patient to see his/her own chart, there must be a paper trail documenting that. Thus, the extremely frustrating paperwork patients must file with the medical records dept.

For the nurse mentioned in the post to decline the PMD access to his patient’s medical chart, she was probably correct (if the PMD does not have privileges at that hospital). HIPAA allows disclosure of medical information between a patient’s providers without direct patient consent, but only between the actual providers (i.e. clinic staff don’t count; an inpatient nurse is definitely a grey area). The nurse has no idea if the PMD Is who he says he is, or has an active, ongoing relationship with the patient in question. Individual hospitals may also have their own policies that are more restrictive than this.

Eric Strong

When I was a hospitalist at a private, community hospital, I started off frequently trying to contact PMDs whenever their patients got admitted to me. I quickly discovered that most PMDs either didn’t return my calls, or otherwise cut me off right away stating that I should just fax them a copy of the patient’s discharge summary. I get it – PMDs feel the crush of needing to see their clinic patients q10-15 min, and they didn’t have time to interrupt their day to talk to me about our mutual patients. I wasn’t upset by this, but I did stop calling them. (though of course, always still faxed d/c sums).

I appreciate that this author (and other PMDs here on KevinMD) may openly welcome direct conversations with the hospitalists. But please realize that you are a minority. The same held true for attempts to sit down with a consultant to discuss a case. Sitting down with more than 1 consultant at a time to talk through a particularly difficult diagnostic or treatment dilemma was literally impossible.

I understand that the hospitalist who goes out of the way to talk to the PMD may also be a minority. We are all busy and all feel pressure to see more patients and get more done during our day.

(I’m now at an academic institution, which is quite different as far as all of the above is concerned – but that’s another discussion.

Brunhilde

This is absolutely true. When I attempt to contact PMDs I am almost always ignored. I recently had a very old, mildly demented woman who would not listen to a word I said because I was not “Dr. Miller”. She requested over and over to speak to him prior to accepting any of my recommendations. I paged this doctor, emailed him and left him a voice mail. Despite the fact that I know he was working (since this patient had a scheduled visit with him on the day she was admitted), I never heard back from him. She spent two days in the hospital and nothing was accomplished because she would not make any changes without hearing from him and he had no interest in speaking to me. It was a very frustrating experience.

http://doctor-rob.org/ Dr. Rob

Yeah, I guess my colleagues are so wrapped up in seeing 40 patients per day and qualifying for meaningful use, they don’t want to be bothered with inconsequential information about the patient being in the hospital. Sad. I’ve never had the opportunity to refuse a phone call from a hospitalist, though. I wouldn’t do that. I’m not sure why this hospitalist chose to ignore the card with my cell # on it and the request from my fill me in. It’s really devolved into something wholly other than a place for patient care.

Steven Reznick

Wonder if you had contacted the medical staff office in advance, or your department head and with the patients permission asked to have access to the chart, if the experience might have been different? I have never had a problem seeing a patient of mine hospitalized where I am not on staff if I speak to the attending physician or hospital administration in advance.
Communication between physicians and doctors and nurses today is deplorable with all sides saying at some point they are too busy. When communication is only by the chart or computer the patient suffers.

http://doctor-rob.org/ Dr. Rob

Well done. Not sure at all why a PCP would refuse a call from a hospitalist. I’ve never had the opportunity to refuse a call from the hospitalist. The frustrating thing for me is that I’ve tried setting up a communication channel with them several times, only to be rebuffed. My patient gave my number to this hospitalist and I never heard anything (even though I gave my cell # and said they could call any time). While my post is sad from my perspective, yours is even more so in it’s spot-on truth about life in the meat grinder.

crnp2001

I hear both sides of the issue, but I work on Dr. Nobody’s side in the outpatient realm. Hell, most of the time, we’re not even NOTIFIED that our patients are in the ER or admitted, thanks to our lousy EMR system (thanks Centricity/CPO). Prior to joining the hospital group, we worked with another private hospitalist group, whose physicians were fabulous at communication.

Not so with the hospital-owned group. Now, you have to politely ask who even answers the on-call phone when trying to request a direct admission. Depending on who is the admission physician on-call, they will actually REFUSE to accept patients! Um…that’s your job, folks! Nope…some of them will defer patients to the ER. What a waste of time and money. But I digress.

And trying to call hospitalists to get updates on a patient’s status? Or sharing important information, recent labs, etc.? Forgettaboutit. #facepalm

jpsoule@hotmail.com

Love the satire! Oh so true!
This is one of the reasons I’m a solo practitioner, despite much less income and told my only son to join the military for his college education.

Eric Strong

That was brilliant!

Eric Strong

I don’t understand. Are you suggesting that a random person who walks up to the nurse’s station in a hospital, and states to whoever is sitting behind the desk: “I’m Dr. Blah Blah, the primary care doctor for Ms. Smith” should be handed the patient’s chart? If that’s how lax your hospital is with its patient records, remind me not to refer anyone there. This is not a matter of misinterpretation of the law, but rather a matter of common sense. You don’t hand over sensitive information to a person without confirming their identity and their right to acquire this information.

This whole issue is moot anyway. Virtually every hospital is now on an EMR. It’s not possible to give an uncredentialed individual access to one person’s chart without giving him/her access to them all. Unless you think the nurse/clerk should print off a disposable paper copy of the patient’s entire chart, and hand it across the desk to the mystery PMD.

Eric Strong

Okay. Sorry I wasn’t able to correct your misunderstanding of basic principles of hospital privacy and security.

http://doctor-rob.org/ Dr. Rob

Bingo. The thing is, I am supposed to be sent a copy of the discharge summary and any hospital information I ask for. So after the patient is in the hospital I am allowed to call and get them to fax me records, but if I go in person while they are there, they won’t give me access? It’s crazy. Plus, the patient is right there and can identify me as their PCP if they need verification.